What is the management for non-intractable (not severe or uncontrolled) migraines in a 17-year-old?

Management of Non-Intractable Migraine in a 17-Year-Old

For a 17-year-old with non-intractable migraine, start with ibuprofen (weight-appropriate dosing) as first-line acute treatment, taken as early as possible during the attack, and consider adding an antiemetic if nausea is present. 1

Acute Treatment Strategy

First-Line Medication

• Ibuprofen is the recommended first-line treatment for children and adolescents with migraine, dosed appropriately for body weight 2, 1
• Acetaminophen alone is less effective than ibuprofen or combination therapy and should be reserved only for patients intolerant of NSAIDs 2, 1
• Administer medication as early as possible during the attack to maximize efficacy—effectiveness depends critically on timing 2, 1, 3

When to Escalate to Triptans

• If ibuprofen fails after 2-3 consecutive attacks, escalate to triptans for moderate-to-severe migraine 2
• Triptans should NOT be used if the patient has uncontrolled hypertension, basilar or hemiplegic migraine, or cardiovascular risk factors 1
• Rizatriptan is particularly useful in adolescents as it comes in an absorbable wafer form, beneficial when nausea develops 3
• Nasal spray formulations (sumatriptan 5-20mg intranasal) are effective when significant nausea or vomiting is present 4, 3

Adjunctive Treatment for Nausea

• Domperidone can be used for nausea in adolescents aged 12-17 years, though oral administration is unlikely to prevent vomiting 2
• If nausea or vomiting is prominent, use a nonoral route of administration and add an antiemetic 1
• Metoclopramide is safe and effective for migraine-associated nausea 1

Critical Medication Overuse Warning

Limit acute treatment to no more than 2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily chronic headaches 4, 3

When to Initiate Preventive Therapy

Indications for Prevention

• Evaluate for preventive treatment if the patient has ≥2 migraine attacks per month causing disability for 3+ days, or uses rescue medication more than twice weekly 1
• Preventive therapy should also be considered if migraine continues to impair quality of life despite optimized acute treatment 2

First-Line Preventive Options for Adolescents

• Propranolol is the first-line preventive medication with the best safety data in children and adolescents 1
• Amitriptyline is an alternative if propranolol is contraindicated 1
• Avoid topiramate, valproate, and candesartan due to potential adverse effects on growth, development, and cognition in this age group 1

Duration and Monitoring

• Preventive therapy efficacy requires 2-3 months for assessment with oral medications 2
• Consider pausing preventive treatment after 6-12 months of success to determine if it can be discontinued 2

Lifestyle Management (Essential Component)

Sleep and Hydration

• Maintain a consistent sleep schedule with adequate hours and ensure proper hydration throughout the day 1
• Poor sleep quality is a predisposing factor that can be modified 2

Exercise and Trigger Identification

• Encourage regular moderate-to-intense aerobic exercise 1
• Use a headache diary to identify specific triggers such as foods, environmental factors, stress, and weather changes 1
• Monitor frequency with headache diary for 8-12 weeks when assessing treatment response 1

Red Flags Requiring Neuroimaging

Obtain neuroimaging if any of the following are present: 1

• Headache worsened by Valsalva maneuver
• Headache that awakens from sleep
• Progressive worsening pattern
• Abnormal neurologic examination findings

Common Pitfalls to Avoid

• Do not allow frequent use of acute medications in response to persistent headaches—this creates medication-overuse headache. Instead, transition to preventive therapy 4
• Bed-rest alone might suffice in children with short-duration attacks, so avoid unnecessary medication exposure when possible 2
• The evidence base for medication therapy in children and adolescents differs from adults—attacks are often shorter, more bilateral, less pulsating, with prominent gastrointestinal symptoms 2
• Family members and teachers should be educated about the condition and management plan, as active help from both is usually necessary 2

Stepped Care Algorithm Summary

1. Mild-moderate attack: Ibuprofen (weight-appropriate) + antiemetic if needed 1
2. Three consecutive failures: Switch to triptan (rizatriptan or nasal sumatriptan preferred) 2
3. ≥2 disabling attacks/month or frequent acute medication use: Initiate propranolol for prevention 1
4. Monitor with headache diary: Reassess at 8-12 weeks 1